Credit Card Payment Plan Authorization Form



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< City State Zip>

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Credit Card Payment Plan Authorization Form

You can pay off your balance with a simple automated payment plan. It’s easy to set-up, and your payments will take care of themselves. Just complete and sign the form below to get started!

Here’s How the Payment Plan Works:

We decide upon a mutually agreeable number of payments and a schedule. You authorize the regularly scheduled charges to your credit card. A receipt will be emailed for each payment that includes information on how much you’ve paid off, how much is left, and your next scheduled payment and date. When the total due is collected, the schedule ends and the authorization is terminated.

Please complete the information below:

Total Due: _________ Payment Frequency: __________________________

# of Payments: _________ Start Date: __________________________

Payment Amount: _________

I ____________________________ authorize to charge my account indicated

(full name)

below to discharge the above debt for _____________________________________, using installment

(description of goods/services)

payments in the amount and schedule indicated.

Billing Address ____________________________ Phone# ________________________

City, State, Zip ____________________________ Email ________________________

|Account Type: Visa MasterCard AMEX Discover |

| |

|Cardholder Name _________________________________________________ |

|Account Number _____________________________________________ |

|Expiration Date ____________ |

SIGNATURE DATE

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. If the above noted payment date(s) fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that this authorization will remain in effect until the debt is fully discharged or I cancel it in writing which ever comes first, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. I certify that I am an authorized user of this credit card and that I will not dispute the payments with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

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